CHAPTER 9 / Nursing Care of Clients with Altered Immunity 267

Nursing Care PlanA Client with HIV Infection

Sara Lu is a 26-year-old elementary school teacher who lives withher parents and two younger sisters.Ms.Lu is very close to her par-ents and sisters; they share everything with each other.During therequired physical for admission to graduate school,Ms.Lu tells herphysician that lately she has felt fatigued. She also states that shehas had a persistent sore throat, intermittent bouts of diarrhea,and mild shortness of breath for about a month. She takes no rou-tine medications other than a daily multivitamin and an occa-sional acetaminophen tablet for a headache. She is active in adrama club in her community, and she jogs 3 miles three to fourtimes a week. She is engaged to be married; her wedding date is 6months away. Her fianc is the only person with whom she hashad sexual relations.Her sexual activity has been unprotected.Ms.Lu has a history of open heart surgery 7 years ago to correct a con-genital valve defect. She has been physically healthy since thattime, until about a month or two ago. The physician orders amononucleosis test, enzyme-linked immunosorbent assay(ELISA),Western blot analysis, CD4 T-cell count, a p24 antigen test,and an erythrocyte sedimentation rate (ESR). She has been askedto return in 1 week for follow-up.

ASSESSMENTOn Ms. Lus follow-up visit, Carole Kee, RN, obtains her nursing his-tory. Ms. Lu continues to have flulike symptoms but has improvedsomewhat. She states that she just has not been as active as usualand is worried about her health. Her appetite has decreased be-cause of soreness in her mouth, and she has noted some whitishpatches on her tongue and cheeks.

A chest X-ray film reveals no abnormality.The results of her lab-oratory tests are as follows:

ELISA: positive for antibodies against HIV Western blot analysis: positive for antibodies against HIV p24 antigen test: positive for circulating HIV antigens ESR: increased to 25 mm/h (normal for women is 15 to 20

mm/h; normal for men is 10 to 15 mm/h) CD4 T-cell count: 599/mm3 (normal range is 600 to 1200 mm3)

Ms. Lus physical examination reveals that she has enlargedlymph nodes in her neck and white patches on her oral mucosa.Her skin is warm to the touch. Her vital signs are as follows:T 99.9F (37.7C), P 84, R 20, and BP 120/78.

Ms. Lu is told of the results of her laboratory tests and the med-ical diagnosis of HIV infection. Ms. Lu is obviously distressed andwants to know how this happened, its meaning, whether she hasinfected her loved ones, and whether she will get better.

DIAGNOSIS Imbalanced nutrition: Less than body requirements related to

soreness in mouth Risk for Deficient fluid volume related to decreased fluid intake

and diarrhea Risk for infection related to altered immune protection Anxiety related to diagnosis and fear Deficient Knowledge about the HIV disease process

EXPECTED OUTCOMES Maintain adequate nutrition for optimal body and cellular

function.

Consume at least 2500 mL of fluid per day. Remain free of infections and their complica-

tions. Verbalize anxiety and use appropriate coping mechanisms. Verbalize and demonstrate knowledge of HIV disease. Verbalize measures to prevent HIV transmission to others, in-

cluding safer sex practices.

PLANNING AND IMPLEMENTATION Monitor daily weight and intake and output. Monitor dietary habits and serum albumin levels. Teach Ms. Lu the importance of consuming a nutritionally bal-

anced diet and maintaining adequate fluid intake. Suggest strategies for coping with anorexia and nausea. Provide dietary consultation referral. Encourage oral care before and after meals. Assess bowel sounds and monitor elimination pattern. Administer antiemetic and antimotility medications as ordered. Monitor for signs of dehydration, such as poor skin turgor,

oliguria, and orthostatic hypotension. Increase fluid to 2500 mL daily. Use strict aseptic technique for all invasive procedures. Teach Ms. Lu to avoid exposure to infection and people with

known illnesses. Administer antiretroviral medications and antibiotics as pre-

scribed, and monitor response. Encourage maintenance of regular physical exercise. Provide opportunities for Ms. Lu to verbalize her feelings. Avoid false reassurances. Provide appropriate and adequate information about

HIV/AIDS. Teach safer sex practices and other measures to prevent HIV

transmission. Teach anxiety-controlling techniques, such as deep breathing

and meditation.

EVALUATIONMs. Lu is eager to learn about her illness and wants her family tocome with her for further explanation. She states that she is sureher fianc will be available as well. Ms. Lu is taking home antifun-gal medication, diet plans, and a schedule for increased exercise.She will return in 1 week for counseling and in 1 month for afollow-up physical.

Critical Thinking in the Nursing Process1. How does age effect the bodys response to fighting HIV?

What other factors affect the risk of HIV infection and its pro-gression?

2. Are the laboratory results for Ms. Lu a true indication that sheis HIV positive? What additional tests might be ordered?

3. What is the most likely source of Ms. Lus infection? Whatmeasures are used to reduce this risk, and how did she con-tract HIV? What is another possible source of Ms. Lus HIVinfection?

4. Ms. Lu says that her fianc would like to have a child. How willyou counsel her regarding pregnancy and childbearing?

See Evaluating Your Response in Appendix C.